Vikas S. Sethi, DO1, Ian Lancaster, MD1, Michael Louis, DO1, Joseph Namey, DO1, Manoj Kumar, MD, MPH2, Meir Mizrahi, MD3 1Largo Medical Center, Largo, FL; 2Carilion Clinic Gastroenterology, Roanoke, VA; 3Florida Digestive Health Specialists, Largo, FL
Introduction: Gastric perforation is a well-recognized medical emergency that can be intervened on endoscopically or via surgical means. From an endoscopic standpoint, perforations can be managed with through/Over the-scope clips (TTS/OTSC) based on the perforation size, endoscopic suturing, or surgical management if endoscopic means are contraindicated.
In this case, we demonstrated a rescue approach for gastric perforation due to PEG tube dislodged.
Case Description/Methods: A 55-year-old patient with a complex medical history presented to GI service with decompensated alcoholic liver cirrhosis, s/p cholecystostomy tube, mechanically ventilated, and with acute renal failure requiring hemodialysis. He had a percutaneous G tube placed 10 days prior to his admission that was accidentally dislodged by the patient due to encephalopatic state. He was under ICU care on multiple antibiotics and pressor support for septic shock with infected ascites due to gastric contents leak into the peritoneal cavity. As the patient was too unstable for surgical intervention, GI was consulted. The PEG site was evaluated via EGD for OTSC closure; however, was deferred due to difficulty in intubating the UES and fragility of the surrounding mucosa. A 450 cm long guidewire was inserted from the percutaneous entry site and did not arrive at the stomach. The XP was advanced through the gastric end of the PEG site and peritoneoscopy was performed to capture and pull the absent wire into the stomach. A balloon PEG was inserted percutaneously into the stomach with tension to tamponade the perforation. Then, an NJ tube was placed via XP endoscope with direct visualization. Twenty-four after, gastrografin injection through the PEG under fluoroscopy confirmed placement with no evidence of extravasation of contrast into peritoneum.
Discussion: This case provides a unique approach for gastric perforation in a patient non-amenable to other interventions. Previously only two cases of PEG replacements in attempts to tamponade gastric perforations in severely ill patients with signs of peritonitis have been documented; This unique case highlight the novel technique using a flexible laparoscopy and a PEG as a means to repair a severe spilling gastric perforation.
Disclosures: Vikas Sethi indicated no relevant financial relationships. Ian Lancaster indicated no relevant financial relationships. Michael Louis indicated no relevant financial relationships. Joseph Namey indicated no relevant financial relationships. Manoj Kumar indicated no relevant financial relationships. Meir Mizrahi indicated no relevant financial relationships.
Vikas S. Sethi, DO1, Ian Lancaster, MD1, Michael Louis, DO1, Joseph Namey, DO1, Manoj Kumar, MD, MPH2, Meir Mizrahi, MD3. P1736 - “Keyhole Espionage- Breaking the Rules Effectively”: A Novel Endoscopic Approach to Tackle Gastric Perforation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
